A Collaborative Care Model for Chronic Disease Management in Diabetes - Involvement of Community Pharmacists in Complex Care Plans, a Pilot Study
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 16
- 主要终点
- Change in HbA1C from baseline at one year
研究概览
简要总结
This project is an initiative to bring physicians, nurses, community pharmacists and patients together in collaborative planning in the management of diabetes, which aligns with the collaborative, team based aspects of family medicine as a community based discipline. Alberta funds both physicians and community pharmacists to complete a comprehensive assessment and plan for patients with qualifying medical conditions. Our research hypothesis is that a collaborative approach between healthcare providers involved in delivering care will improve individual patient outcomes with the primary outcome being improved glycemic control. Health care utilization and medication adherence will also be assessed. This project will compare the results of comprehensive annual health care plans implemented over a period of twelve months with or without involvement from community pharmacists. It is hypothesized that involvement of community pharmacists and their collaboration with physicians will lead to improved outcomes.
详细描述
Research question: Does involvement of a community pharmacist in formulating and following a complex care plan for diabetic patients in conjunction with the patient's clinical team (physician and chronic disease management nurse) improve outcomes including glycemic control, health care utilization and medication adherence.
Hypothesis: Collaborative complex care planning for diabetic patients with the primary care physician, chronic disease management nurse and community pharmacist leads to improvement in patient health outcomes, decreases hospital visits and visits to family physician and emergency room and improves medication adherence.
Aim of the study: The aim of this study is to serve as a pilot in exploring if collaborative care provided by physicians, chronic disease nurse and community pharmacists in formulating and following complex care plans leads to better clinical outcomes when compared to care plans that are formulated and followed in isolation by the physician and chronic disease nurse. This study would be the basis for a future in depth project comparing outcomes of care plans completed in isolation by the pharmacists or physicians with those created in a collaborative environment. Our long-term objectives are improvement in patient outcomes, reduction in health care expenditure as well as preventing duplication and potential discordance of comprehensive care plans.
Methodology
Patients and study design: This is a single centre prospective case control pilot study.
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients who have diabetes with HbA1C over target (>7) and who qualify for a complex care plan completion.
排除标准
- •Pregnancy
- •Unwilling to participate/provide written consent
- •Unable or unwilling to participate in planned follow-ups
研究组 & 干预措施
Community Pharmacist Involvement
Patients would have a complex care plan completed by their clinical team, which will involve chronic disease management nurse and the family physician. This complex care plan would also involve discussion with the patient's community pharmacist who would follow-up with the patient monthly and send a report to the patient's physician. Patients would also continue to receive routine care at the clinic.
The monthly follow-ups with the community pharmacist would involve review of the goals of complex care plan and monitoring clinical targets, medication review and discussing adherence as well as patient education. This follow-up can be completed in person or by telephone. The pharmacist would then send a monthly report to patient's family physician.
干预措施: Community pharmacist involvement (Other)
Usual care
Patients have a complex care plan completed by their clinical team, which will involve the chronic disease management nurse and the family physician and then receive routine care and follow up. They will receive usual care from their community pharmacist.
结局指标
主要结局
Change in HbA1C from baseline at one year
时间窗: 1 year
次要结局
- Change in systolic BP from baseline at one year(1 year)
- Change in diastolic BP from baseline at one year(1 year)
- Change in Low Density Lipoprotein (LDL) from baseline at one year(1 year)
- Change in weight from baseline at one year(1 year)
- Change in BMI from baseline at one year(1 year)
- Change in hospital admissions from baseline at one year(1 year)
- Change in family physician visits from baseline at one year(1 year)
- Change in emergency room visits from baseline at one year(1 year)
- Change in medication adherence from baseline at one year(1 year)
研究者
Divya Garg
Clinical Assistant Professor
University of Calgary